A 59 year old male presents with recent onset of headaches and poor balance when walking. His headaches are worse in the early morning and sometimes they are associated with nausea and vomiting. He has a past history of lung carcinoma, ethanol abuse and hypertension. Physical exam reveals normal vital signs, normal tone and strength in all limbs with bilateral normal muscle stretch reflexes. He exhibits truncal ataxic gait and bilateral papilledema. Laboratory values reveal a macrocytic anemia with elevated liver enzymes (ALT, AST, Alk phos) and normal electrolytes, serum glucose and urinalysis. An EKG reveals atrial fibrillation.

MRI scan of this patient's head and neck is reflected in this image.

1. Based on the clinical presentation and CT scan, this patient's most likely diagnosis is:

A. medulloblastoma

B. cerebellar infarct in the posterior inferior cerebellar artery distribution

C. metastatic carcinoma

D. epidermoid cyst

E. ependymoma

2. Based on the diagnosis, the next logical step in the management of this patient is:

A. treat patient with chemotherapy

B. totally resect the lesion

C. treat patient with anticoagulants and antiarrhythmics

D. discuss sterotactic biopsy procedure with the patient

3. Truncal ataxia, as seen in this patient, may also be seen in patients with which of the following conditions:

A. mid-line cerebellar tumors

B. cerebellar metastatic tumors

C. spinocerebellar ataxias

D. Friedreichs’ ataxia

E. all of the above

The following image represents a biopsy obtained from this patient.

Based on the histology, the diagnosis is:

A. metastatic adenocarcinoma

B. cerebellar hemangioblastoma

C. pilocytic astrocytoma of cerebellum

D. ependymoma

5. Common primary sites of metastatic carcinoma to the brain include:

A. breast carcinoma

B. lung carcinoma

C. renal call carcinoma

D.melanoma

E. all of the above